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Bridging Anticoagulation After CF-LVAD Implantation
S4 Journal of Cardiac Failure Vol. 21 No. 8S August 2015 are needed to determine whether or not recognition and treatment of CI can improve outcomes in these patients.
Post-operative bridging with IV anticoagulation after CF-LVAD implantation appears safe but is not associated with a lower rate of subsequent pump thrombosis.
Figure 1. Figure 1.
009 Table 1.
Heart failure (n 5 27) Age (years) Male African American Smoker History ethanol use Body mass Index Hypertension Coronary artery disease Hyperlipidcmia Diabetes Mellitus MMSE
57.3 6 10.39 19 (70.4%) 8 (29.6%) 21 (77.8%) 6 (22.2%) 35.2 6 8.7 23 (85.2%) 12 (44.4%) 21 (77.8%) 11 (40.7%) 27.7 6 1.91
Control (n 5 21)
P Value
58.3 6 9.26 11 (52.4%) 8 (38.1%) 9 (42.9%) 3 (14.3%) 30.9 6 6.0 9 (42.9%) 2 (9.5%) 10 (47.6%) 3 (14.3 %) 27.7 6 1.62
0.70 0.20 0.54 0.01 0.48 0.02 0.002 0.008 0.03 0.05 0.97
008 Bridging Anticoagulation After CF-LVAD Implantation Indra Bole, Bethany Tellor, Michael Nassif, David Raymer, Anjan Tibrewala, Scott Silvestry, Justin Vader, Shane LaRue; Washington University School of Medicine, Saint Louis, MO Introduction: Since the inception of Continuous-Flow Left Ventricular Assist Devices (CF-LVADs), various anticoagulation protocols have been employed. Recent publications reported an increase in CF-LVAD pump thrombosis (PT) starting in 2011, especially in the early post-implantation period. Though prior studies of post-operative bridging anticoagulation have not demonstrated a benefit, this has not been evaluated in the context of this recent increased incidence of PT. Methods: We retrospectively identified 446 consecutive patients who underwent CF-LVAD implantation between 1/2005 and 9/2014. A univariate Cox proportional hazard model using competing risk methodology was built upon 30 variables known or theorized to be associated with PT. For the period of “unexpected abrupt increase” in PT among HeartMate II CF-LVAD (2011-2013), chart review was conducted to determine the efficacy of intravenous bridging anticoagulation. Patients were divided into cohorts based on receipt and efficacy of IV anticoagulation in the bridging period of postoperative days 1 - 7. Allocated cohorts were patients in whom there was no IV bridging anticoagulation given (n536), patients receiving anticoagulation but not effectively bridged, defined as having an INR ! 2.0 and PTT ! 50 s more than 50% of the bridging period (n590), and patients in whom effective anticoagulation was given, defined as INR O 2.0 or PTT O 50s more than 50% of the bridging period (n543). The primary end point was defined as time to PT. Secondary end points included reoperation, gastrointestinal bleeding (GIB), intracranial hemorrhage (ICH), and death. Results: Median follow up period was 11.0 +/- 9.6 months after continuous flow LVAD implantation. A majority of patients were white, male, and had a median INTERMACS profile of 2. In the univariate Cox proportional hazard model analysis, use of IV anticoagulation was not associated with development of PT (HR 0.872; 95% CI 0.442 - 1.721, p 5 0.69). During the time period of 20112013 PT occurred in 22% of patients in the non-bridged cohort, 16% of patients in the ineffectively bridged cohort, and 21% of patients in the effectively bridged cohort, p 5 0.60 (see figure 1). There was no difference in mortality between the three groups and no difference in time to GIB, ICH, or reoperation. Conclusion:
Cardiac Rotational Mechanics as a Predictor of Favorable Functional and Structural Response After Mechanical Unloading With Cardiac Assist Devices in Advanced Heart Failure Patients Michael J. Bonios1, James Wever Pinzon1, Josef Stehlik1, Abdallah Kfoury2, Edward M. Gilbert1, Rami Alharethi2, Jose Nativi-Nicolau1, Craig H. Selzman1, Mohammad Alsari1, Bruce Reid2, Stephen H. McKellar1, Antigone Koliopoulou1, William Caine2, Dean Y. Li1, James Fang1, Stavros G. Drakos1; 1University of Utah, Salt Lake City, UT; 2Intermountain Medical Center, Salt Lake City, UT Introduction: Impaired qualitative and quantitative left ventricular rotational mechanics strongly predict cardiac remodeling progression and favorable prognosis after myocardial infarction. Given the absence of established predictors of favorable response following mechanical unloading we investigated whether cardiac rotational mechanics assessed by echocardiography can predict myocardial recovery in advanced ischemic and non-ischemic cardiomyopathy patients undergoing longterm mechanical unloading with left ventricular assist devices (LVAD). Methods: 59 advanced chronic heart failure (HF) patients undergoing implantation of LVAD were prospectively investigated (acute HF patients were prospectively excluded), using speckle tracking echocardiography. We evaluated left ventricular (LV) rotational mechanics (apical and basal LV twist, LV torsion] and deformational mechanics [circumferential (CS) and longitudinal strain (LS)] before LVAD implantation. Cardiac recovery post LVAD implantation was defined as (i) final resulting LV ejection fraction (EF) $ 40%, (ii) relative LVEF increase $ 50%, (iii) relative LVESV decrease $ 50% (all 3 required). Results: 12 patients fulfilled the criteria for cardiac recovery (Rec Group). The pre-LVAD implantation findings for the Rec and Non-Rec Groups are summarized in the Table 1. The Rec Group had significantly less impaired pre-LVAD “Peak LV Torsion” compared to the Non-Rec Group. By receiver - operating characteristic curve analysis, pre-LVAD “Peak LV Torsion” of 0.35 degrees/cm had 91% sensitivity and 70% specificity in predicting cardiac recovery. In concordance, qualitative analysis of the direction of LV rotation mechanics (apical and/or basal), before LVAD implantation, revealed that the presence of abnormal rotating pattern minimizes the chance of post-intervention cardiac recovery. Conclusion: Left ventricular quantitative and qualitative rotational mechanics appear to be useful in selecting patients prone to myocardial recovery. Future studies should investigate the utility of these markers in defining sufficient recovery of heart function during mechanical unloading that could lead to durable cardiac recovery following the explantation of the device.
Table 1. Pre-LVAD implantation findings
LV end-diastolic volume (ml) LV end-systolic volume (ml) LV ejection fraction (%) LV circumferential strain (%) LV longitudinal strain (%) Peak LV torsion (degrees/cm)
Rec Group (n512)
Non-Rec Group (47)
P value
226 6 104
268 6 89
NS
181 6 94
213 6 77
NS
20 6 10 -6.8 65.6
17 6 7 -4.5 6 2.7
NS NS
-4.3 6 3.8
-3.5 6 2.9
NS
0.59 6 0.25
0.20 6 0.35
0.001
Post-operative bridging with IV anticoagulation after CF-LVAD implantation appears safe but is not associated with a lower rate of subsequent pump thrombosis.
Figure 1. Figure 1.
009 Table 1.
Heart failure (n 5 27) Age (years) Male African American Smoker History ethanol use Body mass Index Hypertension Coronary artery disease Hyperlipidcmia Diabetes Mellitus MMSE
57.3 6 10.39 19 (70.4%) 8 (29.6%) 21 (77.8%) 6 (22.2%) 35.2 6 8.7 23 (85.2%) 12 (44.4%) 21 (77.8%) 11 (40.7%) 27.7 6 1.91
Control (n 5 21)
P Value
58.3 6 9.26 11 (52.4%) 8 (38.1%) 9 (42.9%) 3 (14.3%) 30.9 6 6.0 9 (42.9%) 2 (9.5%) 10 (47.6%) 3 (14.3 %) 27.7 6 1.62
0.70 0.20 0.54 0.01 0.48 0.02 0.002 0.008 0.03 0.05 0.97
008 Bridging Anticoagulation After CF-LVAD Implantation Indra Bole, Bethany Tellor, Michael Nassif, David Raymer, Anjan Tibrewala, Scott Silvestry, Justin Vader, Shane LaRue; Washington University School of Medicine, Saint Louis, MO Introduction: Since the inception of Continuous-Flow Left Ventricular Assist Devices (CF-LVADs), various anticoagulation protocols have been employed. Recent publications reported an increase in CF-LVAD pump thrombosis (PT) starting in 2011, especially in the early post-implantation period. Though prior studies of post-operative bridging anticoagulation have not demonstrated a benefit, this has not been evaluated in the context of this recent increased incidence of PT. Methods: We retrospectively identified 446 consecutive patients who underwent CF-LVAD implantation between 1/2005 and 9/2014. A univariate Cox proportional hazard model using competing risk methodology was built upon 30 variables known or theorized to be associated with PT. For the period of “unexpected abrupt increase” in PT among HeartMate II CF-LVAD (2011-2013), chart review was conducted to determine the efficacy of intravenous bridging anticoagulation. Patients were divided into cohorts based on receipt and efficacy of IV anticoagulation in the bridging period of postoperative days 1 - 7. Allocated cohorts were patients in whom there was no IV bridging anticoagulation given (n536), patients receiving anticoagulation but not effectively bridged, defined as having an INR ! 2.0 and PTT ! 50 s more than 50% of the bridging period (n590), and patients in whom effective anticoagulation was given, defined as INR O 2.0 or PTT O 50s more than 50% of the bridging period (n543). The primary end point was defined as time to PT. Secondary end points included reoperation, gastrointestinal bleeding (GIB), intracranial hemorrhage (ICH), and death. Results: Median follow up period was 11.0 +/- 9.6 months after continuous flow LVAD implantation. A majority of patients were white, male, and had a median INTERMACS profile of 2. In the univariate Cox proportional hazard model analysis, use of IV anticoagulation was not associated with development of PT (HR 0.872; 95% CI 0.442 - 1.721, p 5 0.69). During the time period of 20112013 PT occurred in 22% of patients in the non-bridged cohort, 16% of patients in the ineffectively bridged cohort, and 21% of patients in the effectively bridged cohort, p 5 0.60 (see figure 1). There was no difference in mortality between the three groups and no difference in time to GIB, ICH, or reoperation. Conclusion:
Cardiac Rotational Mechanics as a Predictor of Favorable Functional and Structural Response After Mechanical Unloading With Cardiac Assist Devices in Advanced Heart Failure Patients Michael J. Bonios1, James Wever Pinzon1, Josef Stehlik1, Abdallah Kfoury2, Edward M. Gilbert1, Rami Alharethi2, Jose Nativi-Nicolau1, Craig H. Selzman1, Mohammad Alsari1, Bruce Reid2, Stephen H. McKellar1, Antigone Koliopoulou1, William Caine2, Dean Y. Li1, James Fang1, Stavros G. Drakos1; 1University of Utah, Salt Lake City, UT; 2Intermountain Medical Center, Salt Lake City, UT Introduction: Impaired qualitative and quantitative left ventricular rotational mechanics strongly predict cardiac remodeling progression and favorable prognosis after myocardial infarction. Given the absence of established predictors of favorable response following mechanical unloading we investigated whether cardiac rotational mechanics assessed by echocardiography can predict myocardial recovery in advanced ischemic and non-ischemic cardiomyopathy patients undergoing longterm mechanical unloading with left ventricular assist devices (LVAD). Methods: 59 advanced chronic heart failure (HF) patients undergoing implantation of LVAD were prospectively investigated (acute HF patients were prospectively excluded), using speckle tracking echocardiography. We evaluated left ventricular (LV) rotational mechanics (apical and basal LV twist, LV torsion] and deformational mechanics [circumferential (CS) and longitudinal strain (LS)] before LVAD implantation. Cardiac recovery post LVAD implantation was defined as (i) final resulting LV ejection fraction (EF) $ 40%, (ii) relative LVEF increase $ 50%, (iii) relative LVESV decrease $ 50% (all 3 required). Results: 12 patients fulfilled the criteria for cardiac recovery (Rec Group). The pre-LVAD implantation findings for the Rec and Non-Rec Groups are summarized in the Table 1. The Rec Group had significantly less impaired pre-LVAD “Peak LV Torsion” compared to the Non-Rec Group. By receiver - operating characteristic curve analysis, pre-LVAD “Peak LV Torsion” of 0.35 degrees/cm had 91% sensitivity and 70% specificity in predicting cardiac recovery. In concordance, qualitative analysis of the direction of LV rotation mechanics (apical and/or basal), before LVAD implantation, revealed that the presence of abnormal rotating pattern minimizes the chance of post-intervention cardiac recovery. Conclusion: Left ventricular quantitative and qualitative rotational mechanics appear to be useful in selecting patients prone to myocardial recovery. Future studies should investigate the utility of these markers in defining sufficient recovery of heart function during mechanical unloading that could lead to durable cardiac recovery following the explantation of the device.
Table 1. Pre-LVAD implantation findings
LV end-diastolic volume (ml) LV end-systolic volume (ml) LV ejection fraction (%) LV circumferential strain (%) LV longitudinal strain (%) Peak LV torsion (degrees/cm)
Rec Group (n512)
Non-Rec Group (47)
P value
226 6 104
268 6 89
NS
181 6 94
213 6 77
NS
20 6 10 -6.8 65.6
17 6 7 -4.5 6 2.7
NS NS
-4.3 6 3.8
-3.5 6 2.9
NS
0.59 6 0.25
0.20 6 0.35
0.001